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Proportion of Cases of Perforated Appendicitis: A Bad Measure of Quality of Care—Reply

Proportion of Cases of Perforated Appendicitis: A Bad Measure of Quality of Care—Reply In reply Dr Andersson's letter to us and his work1 have presented an interesting challenge to a widely held belief that the natural history of acute appendicitis is progression to perforation, absent early intervention. In support of his hypothesis, one argument he makes is reflected in studies that suggest that conservative observation vs aggressive surgical therapy does not result in an increased rate of perforated appendicitis. However, we would respond that the progression to perforation is one that likely unfolds over the course of days, not just hours. This is supported by our clinical experience, in which children with appendicitis who had more than 5 days of symptoms are more likely to be treated using an interval appendectomy pathway (with patients treated initially with antibiotics who return for an elective appendectomy). Beyond clinical experience, the majority of evidence in the literature describes increased rates of perforated appendicitis to be associated with delays in surgical intervention in both adults2,3 and children.4 Thus, we respectfully disagree with Dr Andersson's view that the proportion of perforations is a bad measure of the quality of care, although we look forward to further inquiry on this subject. If we consider as unsettled the hypothesis that untreated appendicitis progresses to perforation with time, we should entertain the alternate explanation for our results that Dr Andersson advances: that decreases in the proportion of perforated cases were caused only by increases in the ratio's denominator; providers in these areas simply diagnosed nonperforated appendicitis more frequently. Our analysis controlled for the effect of health care resource density, including access to computed tomographic scanners, hospitals, and emergency departments; none of these factors were found to influence the ratio of perforated to nonperforated cases. This would be an unexpected finding if the ratio observed depended primarily on the diagnostic capacity for nonperforated appendicitis present within a given geographic area. By contrast, the only significant factor that was associated with changes in the ratio was the density of pediatricians, who presumably provide referral to definitive care but rarely diagnose appendicitis with certainty. There are, of course, many limitations inherent to population-level research. However, we would maintain that our study represents an important opportunity to analyze the health care system at multiple levels for the provision of surgical care to children. Back to top Article Information Correspondence: Dr Abdullah, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St Harvey 319, Baltimore, MD (fa@jhmi.edu). Author Contributions:Study concept and design: Abdullah and Papandria. Acquisition of data: Abdullah. Analysis and interpretation of data: Abdullah, Papandria, and Camp. Drafting of the manuscript: Abdullah, Papandria, and Camp. Critical revision of the manuscript for important intellectual content: Abdullah. Statistical analysis: Abdullah. Administrative, technical, and material support: Papandria. Study supervision: Abdullah. Financial Disclosure: None reported. References 1. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg. 2007;31(1):86-9217180556PubMedGoogle ScholarCrossref 2. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg. 2006;202(3):401-40616500243PubMedGoogle ScholarCrossref 3. Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg. 2006;244(5):656-66017060754PubMedGoogle ScholarCrossref 4. Golladay ES, Sarrett JR. Delayed diagnosis in pediatric appendicitis. South Med J. 1988;81(1):38-423336798PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Proportion of Cases of Perforated Appendicitis: A Bad Measure of Quality of Care—Reply

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References (4)

Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2011.169
Publisher site
See Article on Publisher Site

Abstract

In reply Dr Andersson's letter to us and his work1 have presented an interesting challenge to a widely held belief that the natural history of acute appendicitis is progression to perforation, absent early intervention. In support of his hypothesis, one argument he makes is reflected in studies that suggest that conservative observation vs aggressive surgical therapy does not result in an increased rate of perforated appendicitis. However, we would respond that the progression to perforation is one that likely unfolds over the course of days, not just hours. This is supported by our clinical experience, in which children with appendicitis who had more than 5 days of symptoms are more likely to be treated using an interval appendectomy pathway (with patients treated initially with antibiotics who return for an elective appendectomy). Beyond clinical experience, the majority of evidence in the literature describes increased rates of perforated appendicitis to be associated with delays in surgical intervention in both adults2,3 and children.4 Thus, we respectfully disagree with Dr Andersson's view that the proportion of perforations is a bad measure of the quality of care, although we look forward to further inquiry on this subject. If we consider as unsettled the hypothesis that untreated appendicitis progresses to perforation with time, we should entertain the alternate explanation for our results that Dr Andersson advances: that decreases in the proportion of perforated cases were caused only by increases in the ratio's denominator; providers in these areas simply diagnosed nonperforated appendicitis more frequently. Our analysis controlled for the effect of health care resource density, including access to computed tomographic scanners, hospitals, and emergency departments; none of these factors were found to influence the ratio of perforated to nonperforated cases. This would be an unexpected finding if the ratio observed depended primarily on the diagnostic capacity for nonperforated appendicitis present within a given geographic area. By contrast, the only significant factor that was associated with changes in the ratio was the density of pediatricians, who presumably provide referral to definitive care but rarely diagnose appendicitis with certainty. There are, of course, many limitations inherent to population-level research. However, we would maintain that our study represents an important opportunity to analyze the health care system at multiple levels for the provision of surgical care to children. Back to top Article Information Correspondence: Dr Abdullah, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe St Harvey 319, Baltimore, MD (fa@jhmi.edu). Author Contributions:Study concept and design: Abdullah and Papandria. Acquisition of data: Abdullah. Analysis and interpretation of data: Abdullah, Papandria, and Camp. Drafting of the manuscript: Abdullah, Papandria, and Camp. Critical revision of the manuscript for important intellectual content: Abdullah. Statistical analysis: Abdullah. Administrative, technical, and material support: Papandria. Study supervision: Abdullah. Financial Disclosure: None reported. References 1. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg. 2007;31(1):86-9217180556PubMedGoogle ScholarCrossref 2. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg. 2006;202(3):401-40616500243PubMedGoogle ScholarCrossref 3. Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg. 2006;244(5):656-66017060754PubMedGoogle ScholarCrossref 4. Golladay ES, Sarrett JR. Delayed diagnosis in pediatric appendicitis. South Med J. 1988;81(1):38-423336798PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Jul 18, 2011

Keywords: quality of care,appendix rupture

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